We read with great interest the recent paper by Zaidi et al. (1) demonstrating that T-wave inversion (TWI) in the precordial leads is a nonspecific finding in asymptomatic athletes and that other parameters have to be evaluated before diagnosing arrhythmogenic right ventricular cardiomyopathy (ARVC). This is not so surprising given the century-old observations of Swedish physician Henschen that the cardiac apex is laterally displaced in athletes, thereby also inferring displacement of the right ventricle relative to standardized electrocardiography lead positions. Using magnetic resonance imaging, we recently validated this observation by demonstrating that TWI in leads V1 through V4 was determined by the position rather than morphology of the right ventricle (2). Thus, we agree that TWI can be explained by factors other than right ventricular (RV) pathology in a majority of asymptomatic athletes.

However, precordial TWI should raise the suspicion of ARVC, especially in endurance athletes such as cyclists and triathletes. We coined the term “exercise-induced ARVC” after observing that a majority of athletes presenting for investigation of arrhythmias met task force criteria for ARVC despite the fact that evidence of an inherited syndrome was absent in the vast majority (3,4). Precordial TWI was present in 39% to 71% of those athletes, and, hence, is an important first-line finding to trigger further evaluation. Many of the indicators of RV pathology mentioned by Zaidi et al. corroborate the initial and ensuing reports of our group on this entity that detailed the phenotypic overlap between an athlete’s heart and ARVC. As we recently demonstrated, differentiating between these entities may be far more complex than electrocardiographic assessment and may even require careful assessment of RV function during exercise (5).

Footnotes

Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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